Nursing Diagnosis

Self- Care Deficit

(Grooming and dressing)
Possible Etiologies:
(Related to)
Difficulty in completing
tasks/ loss of previous
capabilities
Defining characteristics:
(Evidenced by)
Subjective:
Mama seems to forget
herself nowadays. So, I
help her clean herself and
wear her clothes every
day. As verbalized by
daughter.
Objective:
-

Inability to maintain
her appearance unlike
before
Forgetfulness (time
and place where she
is)
Inability to recall
previous tasks
Presence of urinary
incontinence as
claimed by daughter
Difficulty articulating
needs
Poor judgement when

Objectives
Short term goal:
Client will be able to
maintain physical care
with less assistance
and on the level of her
ability, after 2 weeks of
intervention.
Long term goal:
Client will be able to
participate in activities
that would promote her
level of functioning and
learn and recall
previous capabilities, at
the end of nursepatient social
interaction.

Nursing Interventions
1. Assess if how is the
client able to meet her
basic needs, who is she
residing with, presence
of visual or hearing
disabilities, and her
usual daily routine.
2. Observe and assess
for her appearance i.e.
appropriate dressing,
disturbances in gait or
movement, presence of
injuries.

Rationale
- It will provide important
information as to how
the client functions at
home and indicate the
need for the degree of
assistance required by
the client.

- Clients with cognitive

impairment often have
some changes in
appearance because of
inability to assume
previous role or
functioning.
3. Check her judgement, -These are indicators to
orientation, memory and the proper functioning of
cognitive abilities.
a person as client with
dementia usually would
4. Build rapport with
require prompting to
client through a calm,
complete tasks.
supportive approach in
- Trust is the main key
interaction.
point in establishing
relationship with the
5. Organize a
client. It would prevent
structured, routine
the client from becoming
schedule of activities
suspicious or delinquent
considering clients
from asking assistance.
abilities while
- It would help client
maximizing her
resume her ADLs
independence.
without overstimulation.
6. Reorient client
frequently by putting her - This would help her
name in bold big letters enhance her memory
in her door or by calling and it would create a
her by name always,
comfortable environment

Evaluation
Client is able to groom
and dress herself with
minimal assistance or
with assistance as
necessary.
Client is participative in
activities like fixing and
feeding self at her own
level of ability,
reminiscing previous
roles and capabilities,
and learning or
relearning tasks
(enhancing memory)
needed for her to
accomplish her ADLs.

assessed

putting a clock and

some familiar pictures in
her room and even
putting the schedule of
activities for a given
day.
7. Provide a safe, nonrestrictive environment
for the client through
proper and adequate
lighting, etc.

8. Encourage enough
resting periods and
adequate sleep.
9. Encourage client to
engage in activities like
music therapy and
dancing; involve client in
simple decision making.
10. Assist client in her
ADLs but as much as
possible let her regain
independence
depending on her
abilities.

for her.
-This would ensure her
safety and would help
prevent harm/ injury
since client may be
disoriented and
confused at times.
-This will help client
regain strength and
energy and would
minimize mood changes
like irritability and some
agitation.
- This will promote
positive self- concept
and her ability to solve
or accomplish simple
tasks.
-By doing this, client will
be able to lessen
dependency and be able
to function with integrity.